Application 1168
Consultation Decision Analytic
Protocol (DAP) to guide the
assessment of the injection of
BOTOX® for prophylaxis of headaches
in adults with chronic
migraine.
January 2012
Table of Contents
MSAC and PASC ........................................................................................................................ 3
Purpose of this document...................................................................................................... 3
Purpose of application .............................................................................................................. 4
Intervention .............................................................................................................................. 4
Description............................................................................................................................. 4
Administration, dose, frequency of administration, duration of treatment.......................... 5
Co-administered interventions .............................................................................................. 6
Background ............................................................................................................................... 7
Current arrangements for public reimbursement ................................................................. 7
Regulatory status ................................................................................................................... 8
Patient population .................................................................................................................... 9
Clinical place for proposed intervention.............................................................................. 10
Comparator ............................................................................................................................. 14
Clinical claim ........................................................................................................................... 14
Outcomes and health care resources affected by introduction of proposed intervention
................................................................................................................................................. 15
Outcomes............................................................................................................................. 15
Health care resources .......................................................................................................... 17
Proposed structure of economic evaluation (decision-analytic) .......................................... 18
Appendix 1: TGA and PBAC status of other pharmaceuticals used for prophylaxis of
migraine. ................................................................................................................................. 20
Appendix 2: Botox uses currently reimbursed by MBS......................................................... 21
References .............................................................................................................................. 24
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 2
MSAC and PASC
The Medical Services Advisory Committee (MSAC) is an independent expert committee appointed by
the Minister for Health and Ageing (the Minister) to strengthen the role of evidence in health
financing decisions in Australia. MSAC advises the Minister on the evidence relating to the safety,
effectiveness, and cost-effectiveness of new and existing medical technologies and procedures and
under what circumstances public funding should be supported.
The Protocol Advisory Sub-Committee (PASC) is a standing sub-committee of MSAC. Its primary
objective is the determination of protocols to guide clinical and economic assessments of medical
interventions proposed for public funding.
Purpose of this document
This document is intended to provide a draft decision analytic protocol that will be used to guide the
assessment of an intervention for a particular population of patients. The draft protocol that will be
finalised after inviting relevant stakeholders to provide input to the protocol. The final protocol will
provide the basis for the assessment of the intervention.
The protocol guiding the assessment of the health intervention has been developed using the widely
accepted “PICO” approach. The PICO approach involves a clear articulation of the following aspects of
the research question that the assessment is intended to answer:
Patients – specification of the characteristics of the patients in whom the intervention is to be
considered for use;
Intervention – specification of the proposed intervention
Comparator – specification of the therapy most likely to be replaced by the proposed
intervention
Outcomes – specification of the health outcomes and the healthcare resources likely to be
affected by the introduction of the proposed intervention
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 3
Purpose of application
A proposal for an application requesting MBS listing of the injection of BOTOX® for prophylaxis of
headaches for adults with chronic migraine was received from Allergan Australia Pty Ltd. by the
Department of Health and Ageing in February 2011.
NHMRC Clinical Trials Centre (CTC), as part of its contract with the Department of Health and Ageing,
drafted this wdecision analytical protocol to guide the assessment of the safety, effectiveness and
cost-effectiveness of BOTOX® for prophylaxis of headaches in adults with chronic migraine in order
to inform MSAC’s decision-making regarding public funding of the intervention.
Intervention
Description
Description of the condition
Chronic daily headache (CDH) occurs on at least 15 days a month (Mayo Clinic, 2010). Chronic
migraine (CM) is a sub-type of chronic daily headache; chronic migraine is defined as a headache on
at least 15 days per month, with at least 8 headache days meeting the criteria for migraine (Olesen et
al. 2006).
The literature differentiates between chronic and episodic migraine; patients with episodic migraine
(EM) – commonly referred to as ‘migraine’ – have headache on less than 15 days per month. Chronic
migraine is distinguished from episodic migraine not only by the number of headache days per month
but also by a greater burden of illness in terms of health‐related quality of life (HRQoL), co-morbid
conditions and health resource use. These differences, as well as physiological data, were used by
Lipton and Chu (2009) to support their argument that CM and EM should be conceptualised as
distinct but related disorders.
A systematic review of quality of life studies in CDH (Lanteri‐Minet et al. 2011) showed that patients
with CDH have consistently worse scoring across most domains of the SF‐36 compared with episodic
headache sufferers and normative controls. The majority of studies found that CDH sufferers with
migrainous features have lower SF‐36 HRQoL scores than those who do not.
The International Burden of Migraine Study (IBMS) found that CM causes significantly greater impact
on HRQoL relative to EM (Blumenfeld et al. 2011). In the American Migraine Prevalence and
Prevention (AMPP) study, patients suffering from CM (N=655) had significantly lower household
income levels than those with EM (N=11,249), were significantly less likely to be employed full time
and nearly twice as likely to be occupationally disabled (Buse et al. 2010). In the IBMS and AMPP
studies, CM was associated with significantly higher rates of co-morbid conditions including anxiety,
depression, obesity and cardiovascular diseases or risk factors (Buse 2010; Blumenfeld 2011).
Additionally, patients with transformed or chronic migraine had significantly more healthcare visits
including GPs, specialists, ER and hospitalisations (Munakata et al. 2009; Blumenfeld et al. 2011).
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 4
Prophylactic treatment for migraine should be considered in patients with recurring migraines that
significantly interfere with their daily routine or in the presence of contraindication to, failure of, or
overuse of acute therapies. The goal of preventive therapy is to reduce the attack frequency, severity
and duration, improve responsiveness to treatment of acute attacks and reduce migraine associated
disability (SIGN Guidelines).
Description of the intervention
Botulinum toxin (BOTOX®) is produced by the gram-positive anaerobic bacterium Clostridium; it is
among the most potent biologic neurotoxins. BOTOX®’s primary mechanism of action is inhibition of
acetylcholine release at the presynaptic cholinergic junction. This results in a reduction of type Ia/II
intrafusal muscle fiber afferent conduction, affecting the spinal stretch reflex and decreasing muscle
tone and contractility without affecting muscle strength (Smaldone et al, 2010). BOTOX®’s analgesic
effects are thought to benefit patients with migraine (NHSC 2010), however, the precise mechanism
of action is not yet certain.
For the prophylaxis of chronic migraine, BOTOX® is injected into multiple sites in the head and neck;
no anaesthetic is required for the injections. The goal of the treatment is to reduce migraine severity
and symptoms.
Administration, dose, frequency of administration, duration of treatment
BOTOX® injections are given at seven specific head and neck areas (frontalis, corrugators, procerus,
occipitalis, temporalis, trapezius and cervical paraspinal) as specified in the BOTOX® product
information and described by Blumenfeld et al. (2010). There are 31 fixed-site, fixed‐dose injections
totalling 155 U and up to an additional 40 U to eight ‘follow the pain’ sites corresponding to the
occipitalis, temporalis and trapezius, for a total maximum dose of 195 U.
Abbreviation: U = Units of BOTOX®
(a) 1 injection site = 0.1 ML = 5 U BOTOX®
(b) Dose distributed bilaterally for minimum dose
Repeated injections are required for this indication because the effect of BOTOX® attenuates after 23 months (8-12 weeks). Therefore, the proposed intervention would be given every 12 weeks / four
times per year.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 5
The pattern of migraine is highly variable, and occasionally associated with hormonal fluctuation
connected to the menstrual cycle, as well as stress, diet and sleep patterns. Therefore, the patient’s
response to therapy should be assessed after two cycles (that is, at 24 weeks), in order to establish
the benefit of BOTOX®.
Duration of delivery is based on patient response. Clinical experts noted that the benefits of BOTOX®
may attenuate over several years of use in some patients. Because incidence of migraine attenuates
past the age of 55, there is no need for an upper limit to the duration of use of BOTOX®.
The procedure is generally performed on patients in the office or in hospital on an out-patient basis.
The Applicant proposes that the item be for delivery only by neurologists, who currently inject
BOTOX® for other indications such as cervical dystonia (spasmodic torticollis).
A concern arises here about the potential for ‘leakage’ to other indications (e.g., episodic migraine,
and cosmetic uses), should this treatment be approved. A requirement that a neurologist carry out
both the diagnosis and the injections would aid in prevention of this ‘leakage.’ However, the Clinical
Experts advised that the number of neurologists using BOTOX® for the treatment of migraine is very
small, and BOTOX® is currently administered for migraine also by plastic surgeons, GPs and other
doctors. Workforce issues may therefore necessitate that neurologists perform the initial diagnosis
and the first two courses of treatment, and other specialists perform subsequent injections. (It needs
to be emphasised here that all specialists delivering BOTOX® must be registered by Medicare
Australia to participate in the arrangements under section 100 of the National Health Act 1953,
relating to the use and supply of Botulinum Toxin.)
Co-administered interventions
Patients are diagnosed as chronic migraine sufferers on the basis of an initial consultation, and a
subsequent headache diary (of between 1-3 months’ length). No ‘objective’ tests are currently
available to determine whether a patient is a chronic migraine sufferer.
The health care resources required on the same day as the injection include: a consultation with a
neurologist, diagnosis, BOTOX® cost, injection cost, needle cost, and cost of the syringes used for
the BOTOX® injection.
Patients who are considered for BOTOX® will have failed or experienced inadequate improvement1
with non-pharmaceutical and/or pharmaceutical therapy. However, some patients may remain on
medications for acute attacks (NSAIDS, triptans) during the treatment with BOTOX®. Nonpharmaceutical therapies currently in use include: a regulation of diet, exercise and sleep, as well as
1
PASC agreed that PBAC needs to address the issues of how to define ‘inadequate improvement,’ and
‘therapy failure.’
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 6
stress management. Pharmaceutical treatment includes preventatives (beta-blockers, calcium channel
blockers, anti-epileptics, serotonin modulators, antidepressants) and/or abortives (analgesics,
triptans) (NHSC 2010).
Background
Current arrangements for public reimbursement
BOTOX® injection for chronic migraines is currently available to patients visiting a neurologist
through self-pay; it is not presently claimable under any MBS item for this indication.
However, BOTOX® is currently reimbursed through MBS for other indications, which include:

hemifacial spasm in a patient 12 years of age or older

cervical dystonia (spasmodic torticollis)

for dynamic equinus foot deformity due to spasticity in an ambulant cerebral palsy patient,
aged two years or older

for dynamic equinovarus foot deformity due to spasticity in an ambulant cerebral palsy
patient, aged two years or older

for dynamic equinovalgus foot deformity due to spasticity in an ambulant cerebral palsy
patient, aged two years or older

for the treatment of focal spasticity in adults

for the treatment of severe primary hyperhidrosis of the axillae

for the treatment of strabismus in children and adults

for the treatment of spasmodic dysphonia

for the treatment of blepharospasm in a patient 12 years of age or older

for the treatment of bilateral blepharospasm in a patient 12 years of age or older
A full listing (including the MBS item numbers) is provided in Appendix 2.
As BOTOX® injection for chronic migraines is not presently claimable under any MBS item, current
utilisation rates are difficult to establish.
Fee information
Allergan did not provide fee information. As noted above, however, BOTOX® injection is currently
reimbursed on the MBS for a range of TGA approved indications. The fees for these items range from
$43.35 to $256.90. Allergan advises that the most similar MBS items are 18352 for cervical dystonia
(spasmodic torticollis) and 18362 for severe primary hyperhidrosis of the axillae. The fees for these
items are $240.30 and $237.35, respectively.
Given that the injection of BOTOX® for prophilaxis of headaches in adults with chronic migraine
involves injections into the head and neck muscles, MBS item 18352 (cervical dystonia, which involves
injection to the head and neck areas (Walker, 2003)) appears to be more similar than MBS item
18362 (severe primary hyperhidrosis of the axillae, which involves injections to the axillae (TalaricoFilho et al, 2007)). However, cervical dystonia requires both deeper and more numerous injections, as
well as requiring electrical recordings during the procedure. In terms of both complexity and time
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 7
involved, the process of injection of BOTOX® for chronic migraine therefore more closely resembles
the injections of BOTOX® for cosmetic purposes than those for cervical dystonia. PASC therefore
agreed that the fee for the injection of BOTOX® for chronic migraine should be modelled on a
consultant physician MBS item 116, as a 20 minute service.
Table 1: MBS descriptor for item 116
The injection of BOTOX® for prophylaxis of headache in adults with chronic migraine will require its
own MBS item number, with paragraph T11.1 of explanatory notes applying. It is worth reiterating
that in light of the aforementioned concerns about ‘leakage’ to other uses, the descriptor needs to
specify strict eligibility criteria.
Table 2: Proposed MBS item descriptor for the injection of BOTOX® for prophylaxis of headaches in
adults with chronic migraine.
The TGA approved indication (TGA entries 172264 and 67311) for BOTOX® is for prophylaxis of
headaches in adults with chronic migraine (headache on at least 15 days per month, of which at least
8 days are with migraine). The requested MBS listing is therefore consistent with the TGA approved
indication (i.e., it is also for the prophylaxis of headaches in adults with chronic migraine, where the
chronic migraine is defined as headache on at least 15 days per month, of which at least 8 days are
with migraine).
Regulatory status
BOTOX® is currently TGA-approved (under TGA entries 172264 and 67311) for a number of
indications, including the prophylaxis of headaches in adults with chronic migraine (headache on at
least 15 days per month of which at least 8 days are with migraine). The other approved indications
(under the same entries) include:
2
Paragraph T11.1 is provided in Appendix 2.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 8

Treatment of strabismus in children and adults;

Treatment of blepharospasm associated with dystonia, including benign blepharospasm and
VII nerve disorders (specifically hemifacial spasm) inpatients twelve years and over;

Treatment of cervical dystonia (spasmodic torticollis);

Treatment of focal spasticity of the upper and lower limbs, including dynamic equinus foot
deformity, due to juvenile cerebral palsy in patients two years of age and older;

Treatment of severe primary hyperhidrosis of the axillae;

Treatment of focal spasticity in adults.

Treatment of spasmodic dysphonia.
BOTOX (Botulinum Toxin Type A) Purified Neurotoxin Complex is indicated for the following cosmetic
indications:

Temporary improvement in the appearance of upper facial rhytides (glabellar lines, crows’
feet and forehead lines) in adults.
An alternative clostridium botulinum type A toxin, Dysport, is also TGA-registered for a more limited
list of indications. Under TGA entries 74124 and 170651 Dysport is specified for the treatment of:

spasticity of the upper limb in adults following a stroke;

spasmodic torticollis in adults;

dynamic equinus foot deformity due to spasticity in ambulant paediatric cerebral palsy

blepharospasm in adults;

hemifacial spasm in adults;

moderate tosevere glabellar lines in adults.
patients, two years of age or older;
Patient population
There is a potential for the size of the population to be much larger than that proposed by the
applicant, depending on how ‘inadequate improvement’ and ‘failure’ of prophylactic pharmaceuticals
are defined within the clinical management algorithm. (PASC agreed that PBAC needs to address the
issue of how to define these concepts.) The size of the patient population may also be increased due
to the aforementioned potential for ‘leakage’ of the service into the episodic migraine patient
population.
BOTOX® is contraindicated for the following patients: individuals with hypersensitivity to ingredients
in the formulation, patients with myasthenia gravis or Eaton Lambert Syndrome, and presence of
infection at the injection site. The effects of the use of BOTOX® in pregnant women are unknown,
therefore BOTOX® should not be used in those patients unless the benefits clearly outweigh the
risks. No information is available on whether BOTOX® is excreted in breast milk, thus the use of
BOTOX® is not recommended whilst breastfeeding.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 9
Clinical place for proposed intervention
European Federation of Neurological Societies (EFNS) guidelines state that prophylactic drug
treatment of migraine should be considered and discussed with the patient when:
•
the quality of life, business duties, or school attendance are severely impaired
•
frequency of attacks per month is two or higher
•
migraine attacks do not respond to acute drug treatment
•
frequent, very long, or uncomfortable auras occur.
A migraine prophylaxis is regarded as successful if the frequency of migraine attacks per month is
decreased by at least 50% within 3 months (EFNS 2009).
Based on these, or similar criteria, all patients with chronic migraine (defined as headache on at least
15 days per month, with at least 8 headache days meeting the criteria for migraine) would be
considered suitable for prophylactic drug treatment. It is assumed that these patients have tried nonpharmaceutical therapies, which include: regulation of diet, exercise, and sleep, as well as stress
management (NHSC 2010).
The SIGN guidelines provide the following general principles for the preventive treatment for
migraine:
•
most preventive drugs should be titrated slowly to an effective or maximum dose, in order to
•
preventive medication should be given a trial of at least six to eight weeks following dose
minimise side effects
titration
•
the choice of preventive medication should be guided by its side effect profile and the
patient’s co-morbid conditions
•
after six to 12 months of effective prophylaxis, gradual withdrawal should be considered
(SIGN Guidelines)
There are a wide range of pharmaceuticals for the preventive treatment of migraine; they are
generally used for this indication after establishing themselves for other indications (Stark and Stark,
2008). Alongside preventive migraine treatment, patients should also have access to appropriate
medications for treatment of acute attacks of migraine such as analgesics (e.g. paracetamol, NSAIDs)
and triptans (serotonin IB/ID
agonists, e.g. sumatriptan, rizatriptan, eletripan, naratripan and
zolmitripan).
According to the recent European Federation of Neurological Societies (EFNS) guidelines, prophylactic
pharmaceuticals of first-choice are:
•
betablockers (metoprolol and propranolol)
•
calcium channel blockers (flunarizine), and
•
antiepileptics (Sodium valproate and topiramate) (EFNS 2009).
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 10
These guidelines consider the antidepressants (amitriptyline and venlafaxine) to be drugs of second
choice. Each of these drugs has specific side effect profiles and choice will depend on the patient’s
profile of co-morbid conditions.
Recent Australian Guidelines list the following drugs as first-line options:

Amitriptyline

Pizotifen

Propranolol
The following drugs are considered second-line options:

Sodium valporate

Topiramate

Verapamil (Therapeutic Guidelines, 2011).
These guidelines, however, reflect only the approved uses of these pharmaceuticals. In practice, a
number of other pharmaceuticals (some of which lack TGA approval and/or PBS reimbursement for
migraine prophylaxis3) are also used for this purpose, as second-line options. They include:

Cypropheptadine

Metoprolol

Methysergide

Clonidine

Candesartan

Lisinopril

Gabapentin (Stark and Stark, 2008).
A wide range of patient non-response to therapies is reported in published studies; clinical experts
estimate that between 5-40% of patients do not respond to non-pharmaceutical therapies,
pharmaceutical therapies, or both.
3
Their TGA and PBS status is indicated in Appendix 1.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 11
Current clinical management algorithm without the proposed intervention
NB: this chart reflects actual (rather than approved) usage of pharmaceuticals.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 12
Current clinical management algorithm with the proposed intervention
As noted above, between 5-40% of patients fail to improve with conservative therapies. BOTOX®
therapy is therefore proposed as a third-line option, as BOTOX® is more invasive than the first- and
second-line conservative options.
NB: this chart reflects actual (rather than approved) usage of pharmaceuticals.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 13
Comparator
The comparator for patients who either fail or experience inadequate improvement with 1st and 2nd
line prophylactics, is the best current practice, i.e. 1st and 2nd line prophylactic pharmaceuticals. PASC
accepted that ‘failure’ and ‘inadequate improvement’ needs to be defined by PBAC.
Clinical claim
Because the application is a co-dependent technology (with BOTOX® to be assessed by PBAC and
the injection of BOTOX® to be assessed by MSAC), Allergan has requested that the majority of the
evaluative work (namely the comparative safety and effectiveness of the BOTOX® treatment, as well
as the economic evaluation) be carried out by PBAC. Allergan has requested that MSAC’s evaluation
be circumscribed to the appropriate rebate for the injection procedure.
PASC agrees that the safety, effectiveness and cost effectiveness of BOTOX® should be assessed by
PBAC, whilst the safety, effectiveness and cost-effectiveness of the delivery method (i.e., the
injection) should be assessed by MSAC. However, as this is a co-dependent technology, the
assessment of the delivery method will be modified by the assessment of the drug. Therefore, the
data concerning BOTOX®’s safety and efficacy (which was presented to PBAC) will need to be
considered by MSAC, as well.4
The safety issues to be considered here, include:
bleeding, infection, pain from the injections,
cosmetic side-effects from the injections (e.g. facial asymmetry from local muscle weakness near an
injection
site),
generalised
weakness,
hyper-sensitivity
(allergic)
reaction,
potentiation
of
anticholinergic effects (e.g., dryness of mouth and nose), headache (including worse migraine),
myalgia, seizures; less frequently also a weakness remote from the injection site (e.g. neck weakness
or impaired swallowing).
The effectiveness issues to be considered, include changes in: frequency of headache episodes,
frequency of headache days, frequency of migraine episodes, frequency of migraine days, frequency
of acute pain medication intake, frequency of prophylactic medication intake, change in number of
moderate/severe headache days, changes in cumulative headache hours on headache days, changes
in Headache Impact Test (HIT) score and percentage of patients with a severe HIT score.
As stated, the economic evaluation of the BOTOX® treatment would be carried out by PBAC and
therefore Table 3 was not completed for this application. However, MSAC’s assessment should
consider the financial implications to the MBS of funding the new item (cost of the injection into the
head and heck areas). Moreover, the projected user population for this indication (prophylaxis of
migraine in chronic migraine patients) will need to be established, as well as the size of the
4
PBAC considered Allergan’s application in its November 2011 meeting. The application was rejected on the
basis of uncertain clinical benefit, and high and highly uncertain cost‐effectiveness. Allergan intends to re‐
submit its application to PBAC in March 2012. http://www.pbs.gov.au/info/industry/listing/elements/pbacmeetings/pbac‐outcomes/2011‐11/1st‐time‐decisions
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 14
population of episodic migraine patients and the potential for ‘leakage’ to that population should this
item be placed on the MBS.
Comparative
safety
versus comparator
Table 3:
Classification of an intervention for determination of economic evaluation
to be presented
Comparative effectiveness versus comparator
Superior
Non-inferior
Inferior
Net
clinical
CEA/CUA
benefit
Superior
CEA/CUA
CEA/CUA
Neutral benefit CEA/CUA*
Net harms
None^
Noninferior
CEA/CUA
Inferior
Net
clinical
CEA/CUA
benefit
None^
Neutral benefit CEA/CUA*
Net harms
None^
CEA/CUA*
None^
None^
Abbreviations: CEA = cost-effectiveness analysis; CUA = cost-utility analysis
* May be reduced to cost-minimisation analysis. Cost-minimisation analysis should only be presented
when the proposed service has been indisputably demonstrated to be no worse than its main
comparator(s) in terms of both effectiveness and safety, so the difference between the service
and the appropriate comparator can be reduced to a comparison of costs. In most cases, there
will be some uncertainty around such a conclusion (i.e., the conclusion is often not indisputable).
Therefore, when an assessment concludes that an intervention was no worse than a comparator,
an assessment of the uncertainty around this conclusion should be provided by presentation of
cost-effectiveness and/or cost-utility analyses.
^ No economic evaluation needs to be presented; MSAC is unlikely to recommend government
subsidy of this intervention
Outcomes and health care resources affected by introduction of
proposed intervention
Outcomes
This assessment will consider:

Safety of the injection of BOTOX® into the head and neck areas
o
Bleeding
o
Infection
o
Pain from the injections
o
Cosmetic side-effects from the injections (e.g. facial asymmetry from local muscle
weakness near an injection site)
o
generalised weakness
o
hyper-sensitivity (allergic) reaction
o
potentiation of anticholinergic effects
o
headache (including worse migraine)
o
myalgia
o
seizures
o
weakness remote from the injection site (e.g. neck weakness or impaired swallowing)
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 15


Effectiveness of the injection (as modified by evidence of the effectiveness of BOTOX®)
o
Frequency of headache episodes
o
Frequency of headache days
o
Frequency of migraine episodes
o
Frequency of migraine days
o
Frequency of acute pain medication intake
o
Frequency of prophylactic medication intake
o
Change in the number of moderate/severe headache days
o
Changes in cumulative headache hours on headache days
o
Changes in Headache Impact Test (HIT) score
o
Percentage of patients with a severe HIT score
Cost-effectiveness:
o
Cost of injection of BOTOX® into the head and neck areas
o
Size of the chronic migraine patient population
o
Size of the episodic migraine patient population (and potential for ‘leakage’)
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 16
Health care resources
Table 4:
List of resources to be considered in the economic analysis
Setting Proporti
of
Provider in which on
of
resource patients
receiving
resource is
provided resource
Number Disaggregated unit cost
of units
of
resource
per
relevant
Other Private
Safety
Total
time
MBS
govt
health Patient
cost
nets*
horizon
budget insurer
per
patient
receiving
resource
Resources provided to identify eligible population
‐ Resource 1
‐ Resource 2, etc
Resources provided to deliver comparator 1
‐ Resource 1
‐ Resource 2, etc
Resources provided in association with comparator 1 (e.g., pre-treatments, co-administered interventions, resources used
to monitor or in follow-up, resources used in management of adverse events, resources used for treatment of downstream conditions): Current best practice
Neurologist Outpatient
‐ Resource 1
consult
‐ Resource 2, etc
Resources provided to deliver comparator 2, etc
‐ Resource 1
‐ Resource 2, etc
Resources provided in association with comparator 2, etc
‐ Resource 1
‐ Resource 2, etc
Resources provided to deliver proposed intervention
‐ Resource 1
‐ Resource 2, etc
Resources provided in association with proposed intervention
‐ Resource 1
‐ Resource 2, etc
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 17
Proposed structure of economic evaluation (decision-analytic)
Table 5: Summary of extended PICO to define research question that assessment will
investigate
Patients
Intervention
Comparator
Outcomes to be
assessed
Patients ≥ 15
headache days per
month, of which 8
are with migraine,
who either fail or
experience
inadequate
improvement with
1st and 2nd line
prophylactics
Injection of
BOTOX® into head
and neck areas
Best current
practice, i.e. 1st and
2nd line prophylactic
pharmaceuticals
Safety:
 Bleeding
 Infection
 Pain from the
injections
 Cosmetic sideeffects
 Generalised
weakness
 Hyper-sensitivity
(allergic) reaction
 Anticholinergic
effects
 Headache
 Myalgia
 Seizures
 Weakness remote
from the injection
site
Healthcare
resources to be
considered
Cost of the injection
of BOTOX® into
head and neck
areas
Size of the chronic
migraine patient
population
Size of the episodic
migraine patient
population and the
potential for
‘leakage’
Effectiveness:
 Freq. of headache
episodes
 Freq. of headache
days
 Freq. of migraine
episodes
 Freq. of migraine
days
 Freq. of acute pain
medication intake
 Freq. of
prophylactic
medication intake
 Change in no. of
moderate/severe
headache days
 Change in
cumulative
headache hrs on
headache days
 Changes in HIT
score
 % of patients with
severe HIT score
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 18
Figure 1: Decision Analytic Tree
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 19
Appendix 1: TGA and PBAC status of other pharmaceuticals
used for prophylaxis of migraine.
Drug
TGA status
PBS status
Cyproheptadine
Migraine
Restricted benefit – prevention
of migraine
Metoprolol
Prevention of migraine
General benefit
Methysergide
Prophylaxis of migraine
General benefit
Clonidine
Prophylaxis of migraine
General benefit
Candesartan
Not registered for migraine
General benefit (cardiovascular)
Lisinopril
Not registered for migraine
General benefit (cardiovascular)
Gabapentin
Not registered for migraine
Authority required (streamlined)
(Stark and Stark, 2008; PBS online http://www.pbs.gov.au/pbs/home accessed January 6th, 2012)
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 20
Appendix 2: Botox uses currently reimbursed by MBS
MBS 18350
BOTULINUM TOXIN (Botox), injection of, for hemifacial spasm in a patient 12 years of age or older, including all
injections on any one day
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
MBS 18352
BOTULINUM TOXIN (Botox or Dysport), injection of, for cervical dystonia (spasmodic torticollis), including all
injections on any one day
(See para T11.1 of explanatory notes to this Category)
Fee: $240.30
MBS 18354
BOTULINUM TOXIN (Botox or Dysport), injection of, for dynamic equinus foot deformity due to spasticity in an
ambulant cerebral palsy patient, aged two years or older, in accordance with the supply of the drug under
instrument PB 122 of 2008 (Arrangements — Botulinum Toxin Program) made under Section 100 (1) (b) of the
National Health Act 1953, including all such injections on any one day for all or any of the muscles subserving
one functional activity and supplied by one motor nerve - applicable only to the first two treatments of each limb
of the patient on any one day
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
MBS 18356
BOTULINUM TOXIN (Botox or Dysport), injection of, for dynamic equinovarus foot deformity due to spasticity in
an ambulant cerebral palsy patient, aged two years or older, in accordance with the supply of the drug under
instrument PB 122 of 2008 (Arrangements — Botulinum Toxin Program) made under Section 100 (1) (b) of the
National Health Act 1953, including all such injections on any one day for all or any of the muscles subserving
one functional activity and supplied by one motor nerve - applicable only to the first two treatments of each limb
of the patient on any one day
(Anaes.)
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
MBS 18358
BOTULINUM TOXIN (Botox or Dysport), injection of, for dynamic equinovalgus foot deformity due to spasticity
in an ambulant cerebral palsy patient, aged two years or older, in accordance with the supply of the drug under
instrument PB 122 of 2008 (Arrangements — Botulinum Toxin Program) made under Section 100 (1) (b) of the
National Health Act 1953, including all such injections on any one day for all or any of the muscles subserving
one functional activity and supplied by one motor nerve - applicable only to the first two treatments of each limb
of the patient on any one day
(Anaes.)
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
MBS 18360
BOTULINUM TOXIN (Botox), injection of, for the treatment of focal spasticity in adults, including all injections
for all or any of the muscles subserving one functional activity, supplied by one motor nerve, with a maximum of
4 treatments per patient on any one day (2 per limb)
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
MBS 18361
Botulinum toxin (Botox), injection of, for the treatment of moderate to severe upper limb spasticity due to
cerebral palsy, in a patient who is at least 2 years but less than 18 years, in association with either: (a)
physiotherapy or occupational therapy or both; or (b) electrical stimulation or ultrasound for muscle localisation;
including all injections for any or all of the muscles sub-serving one functional activity supplied by one motor
nerve - with a maximum of four treatments per patient on any one day, and with a maximum of two treatments
per limb
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 21
(Anaes.)
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
MBS 18362
BOTULINUM TOXIN (Botox), injection of, for the treatment of severe primary hyperhidrosis of the axillae,
including all such injections on any one day
(See para T11.1 of explanatory notes to this Category)
Fee: $237.35
MBS 18366
BOTULINUM TOXIN (Botox), injection of, for the treatment of strabismus in children and adults, including all
such injections on any one day and associated electromyography
(See para T11.1 of explanatory notes to this Category)
Fee: $150.50
MBS 18368
BOTULINUM TOXIN (Botox), injection of, for the treatment of spasmodic dysphonia, including all such injections
on any one day
(See para T11.1 of explanatory notes to this Category)
Fee: $256.90
MBS 18370
BOTULINUM TOXIN (Botox), injection of, for the treatment of blepharospasm in a patient 12 years of age or
older, including all such injections on any one day.
(See para T11.1 of explanatory notes to this Category)
Fee: $43.35
MBS 18372
BOTULINUM TOXIN (Botox), injection of, for the treatment of bilateral blepharospasm in a patient 12 years of
age or older, including all such injections on any one day
(See para T11.1 of explanatory notes to this Category)
Fee: $120.10
T.11.1. BOTULINUM TOXIN - (ITEMS 18350 TO 18373)
The Therapeutic Goods Administration (TGA) assesses each indication for the therapeutic use of
botulinum toxin on an individual basis. There are currently two botulinum toxin agents with TGA
registration (Botox and Dysport). Each has undergone a separate evaluation of its safety and efficacy
by the TGA as they are neither bioequivalent, nor dose equivalent. When claiming under an item for
the injection of botulinum toxin, only the botulinum toxin agent specified in the item can be used.
Benefits are not payable where an agent other than that specified in the item is used.
The TGA assesses each indication for the therapeutic use of botulinum toxin by assessment of clinical
evidence for its use in paediatric or adult patients. Where an indication has been assessed for adult
use, data has generally been assessed using patients over 12 years of age. Paediatric indications have
been assessed using data from patients under 18 years of age. Botulinum toxin should only be
administered to patients under the age of 18 where an item is for a paediatric indication, and patients
over 12 years of age where the item is for an adult indication, unless otherwise specified.
Items for the administration of botulinum toxin can only be claimed by a medical practitioner who is
registered by Medicare Australia to participate in the arrangements under Section 100 of the National
Health Act 1953 relating to the use and supply of Botulinum Toxin.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 22
Items 18354, 18356 and 18358 for the treatment of equinus, equinovarus or equinovalgus are limited
to a maximum of 4 injections per patient on any one day (2 per limb). Accounts should be annotated
with the limb which has been treated.
Item 18292 may not be claimed for the injection of botulinum toxin, but may be claimed where a
neurolytic agent (such as phenol) is used, in addition to botulinum toxin injection(s), to treat the
obturator nerve in patients with a dynamic foot deformity.
Items 18354 to 18358 have been extended to patients 18 years of age and older who have
commenced on the PBS subsidised treatment as a paediatric patient. This is in line with the extension
of the PBS listing for the supply of the drug for this indication under Section 100(1)(b) of the National
Health Act 1953.
Botulinum Toxin, which is not supplied and administered in accordance with the arrangements under
Section 100 of the National Health Act 1953, is not free of charge to patients. Where a charge is
made for the Botulinum Toxin administered, it must be separately listed on the account and not billed
to Medicare.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 23
References
Blumenfeld, A., Varon, S., Wilcox T., et al. (2011). Disability, HRQoL and resource use among chronic
and episodic migraineurs: results from the International Burden of Migraine Study (IBMS). Cephalagia
31(3), 301-15
Buse, D.C., Manack, A., Serrano, D. (2010). Sociodemographic and comorbidity profiles of chronic
migraine and episodic migraine sufferers. J Neurol Neurosurg Psychiatry 81(4), 428-432.
European Federation of Neurological Societies (EFNS) Taskforce. (2009). EFNS guideline on the drug
treatment of migraine – revised report of an EFNS task force. European Journal of Neurology 16,
968–981
Lanteri-Minet, M., Duru, D., Mudge, M. et al (2011). Quality of life impairment, disability and
economic burden associated with chronic daily headache, focusing on chronic migraine with or
without medication overuse: a systematic review. Cephalagia 31(7), 837-50.
Lipton R.B. and Chu, M.K. (2009) Conceptualising the relationship between chronic migraine and
episodic migraine. Expert Rev. Neurother. 9(10), 1451-4.
Mayo Clinic (2010). Chronic Daily Headaches: Symptoms. Retrieved on: 8th November, 2011.
Available
at:
http://www.mayoclinic.com/health/chronic-daily-
headaches/DS00646/DSECTION=symptoms
Munakata, J., Hazard, E., Serrano D., et al. (2009). Economic Burden of Transformed Migraine:
Results From the American Migraine Prevalence and Prevention (AMPP) Study. Headache 49, 498508.
National Horizon Scanning Centre (NHSC) (May 2010). Botulinum toxin type A (Botox) for chronic
migraine. Available at: http://www.nhsc-healthhorizons.org.uk/topics/botulinum-toxin-type-a-botox/
Olesen, J., Bousser M-G., Diener H-C., et al (2006). New appendix criteria open for a broader concept
of chronic migraine. Cephalalgia 26(6), 742-6.
Scottish Intercollegiate Guidelines Network (SIGN) (November 2008). Diagnosis and management of
headache in adults: A national clinical guideline. Available at: http://www.sign.ac.uk/pdf/sign107.pdf
Smaldone, M.C., Ristau, B.T., Leng, W.W. (2010). Botulinum Toxin Therapy for Neurogenic Detrusor
Overactivity. Urol Clin N Am 37, 567–580
Stark, RJ and Stark CD. (2008). Migraine prophylaxis. MJA 189(5), 283-288
Talarico-Filho, S., do Nascimento M., de Macedo, F., et al. (2007). A Double-Blind, Randomized,
Comparative Study of Two Type A Botulinum Toxins in the Treatment of Primary Axillary
Hyperhidrosis. Dermatol Surg 33, S44–S50
Therapeutic Guidelines (2011). What’s new, and why, in Neurology 4? North Melbourne: Therapeutic
Guidelines Ltd. Available at: http://opac.library.usyd.edu.au/record=b3385156~S4
Walker, Francis O. (2003). Botulinum toxin therapy for cervical dystonia. Phys Med Rehabil Clin N Am
(14), 749-766.
Application 1168: BOTOX® for prophylaxis of headaches in adults with chronic migraine. 24